All patients scheduled for major elective non-cardiac surgery requiring general
anesthesia and a hospital stay qualify. Patients for emergency surgery,
hemodynamically unstable patients, and renal transplant patients need to be
assessed individually. These guidelines are intended to provide
supplemental information for use with the perioperative beta blockade protocol
order form.

Consider PPBB for patients with in least one of
the following categories:

Care must be taken with administration to patients with a history of asthma
or COPD.

Drug Choice:

Atenolol, bisoprolol and metoprolol may all been used. They are all
long-acting, Beta-1 selective and have similar efficacy in the prevention of
death after myocardial infarction. Other beta blockers without intrinsic
sympathomimetic effect are probably equivalent, so if a patient is on another
beta blocker it is unnecessary to change to a Beta-1 selective drug.
However, the dosage should be adjusted to keep the HR < 80 bpm.

How should PPBB be initiated?

Preoperatively: If Hr > 60 bpm and SBP >
100 mmHg, then oral dosing with twice daily metoprolol (25-50 mg’s), or once
daily atenolol (50-100 mg’s) can be started several days before surgery.
Target HR is >50 and < 70 bpm.

Post Operative Care: If the patient is to be
kept NPO, metoprolol 2.5-5 mg’s IV q 6 hours dosing should be continued with
target HR> 50 and < 70 bpm while maintaining SBP > 100 mmHg. When
patient is able to take oral medications the patient may be switched to twice
daily oral metoprolol (25-50 mg’s), or once daily atenolol (50-100 mg’s)
with dosage adjusted to keep HR > 50 and

< 70 bpm and SBP > 100 mmHg. Consider use of PBBP order form.

PPBB should be continued for at least 7 days
postoperatively. Patients with a history of coronary artery disease may
benefit from indefinite beta blockade therapy.